Basic Information
| Provider Information | |||||||||
| NPI: | 1518939750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | JENIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 MOUNT HOLYOKE CT | ||||||||
| Address2: | |||||||||
| City: | GETZVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140681283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168684877 | ||||||||
| FaxNumber: | 7166880432 | ||||||||
| Practice Location | |||||||||
| Address1: | 292 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140521650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166521560 | ||||||||
| FaxNumber: | 7166880432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 172214 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10166190 | 01 | NY | FIDELIS | OTHER | 00010164304 | 01 | NY | UNIVERA | OTHER | 000524001006 | 01 | NY | BC/BS | OTHER | 0408107 | 01 | NY | IHA | OTHER | 151114BJ | 01 | NY | PREFERRED CARE | OTHER | 01608680 | 05 | NY | MEDICAID |